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Risk factors for patients with psoriasis developing psoriatic arthritis, and potential pharmacological and non-pharmacological interventions.
Patients with psoriasis have a life-long risk for developing concomitant psoriatic arthritis. Prof. Laura Coates, MBChB, MRCP, of the University of Oxford, in the U.K., discussed the risk factors for developing psoriatic arthritis and potential pharmacological and non-pharmacological interventions.
The problem with identifying patients likely to progress to psoriatic arthritis is that “it is not exactly a linear line,” said Prof. Coates1. “It is a process with different levels of disease progression and probably different stages of that disease. So how do we identify those populations with pre-psoriatic arthritis?”
Risk Factors for Psoriatic Arthritis in Patients With Psoriasis
Based on current evidence, the risk for developing psoriatic arthritis is increased by a positive family history, higher psoriasis severity, longer psoriasis duration, presence of arthralgia, stiffness and fatigue, obesity (BMI>35), uveitis, and thyroid disease history2. Other risk factors include the site of psoriasis, hyperlipidaemia, depression, and smoking. It should be noted that people who did not develop psoriatic arthritis after a very long psoriasis duration will more likely not develop the disease.
The PRESTO tool was developed to predict psoriatic risk based on 635 patients with psoriasis without psoriatic arthritis followed prospectively between 2006–2020 (mean follow-up of 7.7 years)3. Development of psoriatic arthritis within 1 year was predicted by younger age, male sex, family history of psoriasis, back stiffness, nail pitting, level of stiffness, and use of biologic medications. The 5 year risk was predicted by morning stiffness, psoriatic nail lesion, psoriasis severity, fatigue severity, pain severity, and use of systemic non-biologic medication/phototherapy.
Preventing Psoriatic Arthritis
“At the moment, we only treat when people get a psoriatic arthritis diagnosis,” said Prof. Coates1. But interventions should ideally happen earlier, during the subclinical or prodromal stages before clinical psoriatic arthritis. “The question is: if we intervene early, can we completely change the outcome and keep the disease under control?”
Lifestyle interventions are a potential way to prevent psoriatic arthritis. Prof. Coates presented unpublished data based on 2,604 patients with psoriasis from the UK Biobank longitudinal study1. These patients were asked to wear an accelerometer to track their physical activity and the addition of 1,000 steps per day reduced the risk for developing psoriatic arthritis by 10%. Furthermore, one hour a day of moderate-to-vigorous physical activity was associated with a lower risk for developing psoriatic arthritis (HR 0.74; 95% CI 0.62–0.87).
In terms of pharmacological interventions, the IVEPSA study assessed secukinumab in 20 participants with moderate-to-severe psoriasis or with nail/scalp involvement and no psoriatic arthritis4. Most participants in this trial had arthralgia and inflammatory lesions determined by imaging. Following 24 weeks of treatment, secukinumab significantly improved arthralgia, synovitis, and bone mass in the distal radius, with no progression in erosion or enthesophytes.
Take-Home Message
“There is a huge potential with an easily identifiable pre-psoriatic arthritis population,” said Prof. Coates, but “we need to evaluate that risk more accurately and get the right group of people into the studies. Biologicals are likely to reduce risk, but the question truly is whether this is changing the evolution of the disease or masking the disease.” Finally, Prof. Coates said that “we need to know which drug is best and it might not be the same drug preventing disease that also treats the disease.”
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